Effects of a home-based walking training program on cardiorespiratory fitness in breast cancer patients receiving adjuvant chemotherapy: a pilot study

BACKGROUND

Breast cancer treatment is associated with a decline in measured cardiorespiratory fitness and increased fatigue. There is accumulating evidence that exercise training during adjuvant chemotherapy may contribute to prevent these changes. Additional studies are needed to explore the effectiveness of home-based walking interventions among this population.

AIM

The aim of this study was to investigate the effects of a 12-week adapted home-based walking training program (WTP) on clinical rehabilitation in breast cancer patients receiving adjuvant chemotherapy.

DESIGN

This was a pilot study using a single-group design.

SETTING

Unit Department of Physiology and Medical Oncology, Limoges University Hospital, France.

POPULATION

Thirty-nine outpatients predominantly with stage II breast cancer.

METHODS

Participants performed 3 home ambulatory aerobic walking sessions per week at 50-60% of their maximum heart rate for 12 weeks. Functional capacity was assessed with an incremental cardiopulmonary exercise test during which peak oxygen consumption (VO(2peak)) was measured. A six-minute walking test (6 MWT) was performed to evaluate physical function. The revised Piper Fatigue Scale (PFS-R) was used to measure self-reported fatigue.

RESULTS

Thirty-four patients (87%) completed all study procedures. Per Protocol (PP) analysis indicated that VO(2peak) recorded both before and after a 12-week adapted home-based WTP increased significantly by 2.21 mL.kg-1.min-1 (P=0.008) and 6 MWT distance increased significantly by 42 m (P=0.04). PFS-R score increased by 0.4 points, but not significantly.

CONCLUSION

In breast cancer patients receiving adjuvant chemotherapy, home-based WTP is feasible and associated with significant improvements in VO(2peak), with no significant effect on fatigue score. Larger randomized trials are necessary to confirm these findings.

Diagnostic accuracy of early urinary index changes in differentiating transient from persistent acute kidney injury in critically ill patients: multicenter cohort study

INTRODUCTION

Urinary indices have limited effectiveness in separating transient acute kidney injury (AKI) from persistent AKI in ICU patients. Their time-course may vary with the mechanism of AKI. The primary objective of this study was to evaluate the diagnostic value of changes over time of the usual urinary indices in separating transient AKI from persistent AKI.

METHODS

An observational prospective multicenter study was performed in six ICUs involving 244 consecutive patients, including 97 without AKI, 54 with transient AKI, and 93 with persistent AKI. Urinary sodium, urea and creatinine were measured at ICU admission (H0) and on 6-hour urine samples during the first 24 ICU hours (H6, H12, H18, and H24). Transient AKI was defined as AKI with a cause for renal hypoperfusion and reversal within 3 days.

RESULTS

Significant increases from H0 to H24 were noted in fractional excretion of urea (median, 31% (22 to 41%) and 39% (29 to 48%) at H24, P<0.0001), urinary urea/plasma urea ratio (15 (7 to 28) and 20 (9 to 40), P<0.0001), and urinary creatinine/plasma creatinine ratio (50 (24 to 101) and 57 (29 to 104), P=0.01). Fractional excretion of sodium did not change significantly during the first 24 hours in the ICU (P=0.13). Neither urinary index values at ICU admission nor changes in urinary indices between H0 and H24 performed sufficiently well to recommend their use in clinical setting (area under the receiver-operating characteristic curve≤0.65).

CONCLUSION

Although urinary indices at H24 performed slightly better than those at H0 in differentiating transient AKI from persistent AKI, they remain insufficiently reliable to be clinically relevant.

High-risk prostate cancer treated with pelvic radiotherapy and 36 versus 18 months of androgen blockade: Results of a phase III randomized study

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Background: Radiotherapy (RT) and long term androgen blockade (AB) is standard treatment for patients with high risk prostate cancer. However, the optimal duration of AB is not yet defined. The purpose of this randomized study was to compare outcomes between 36 vs. 18 months of AB in high risk prostate cancer treated with RT (PCS IV trial, Clinical Trials.gov, #NCT00223171). Methods: PCS IV randomized patients with node negative high risk prostate cancer (T3-4, PSA >20 ng/ml or Gleason score >7), to pelvic RT (whole pelvis 44 Gy/4 ½ weeks, prostate 70 Gy/7 weeks) and 36 (arm 1) vs. 18 months (arm 2) of AB (neo adjuvant, concomitant, adjuvant). AB consisted of bicalutamide 50 mg for one month plus goserelin 10.8 mg every three months for 36 vs. 18 months. Overall survival was the primary end point. Overall and cancer specific survival rates were compared between arms with Kaplan-Meier log rank test and Cox regression. Results: From October 2000 to January 2008, 310 patients were randomized to arm 1 and 320 to arm 2. Patients’ characteristics were well balanced between the two arms (median age 71 years, median PSA 16 ng/ml, median Gleason score 8). Most patients had T2-3 disease. At a median follow-up of 77 months, 71/310 patients (22.9%) in arm 1 and 76/320 (23.8%) in arm 2 had died (p=0.802). Overall, 116 patients died of causes other than prostate cancer. Overall and cancer specific survival hazard ratios were 1.15 (0.83-1.59), p=0.398 and 1.13 (0.61-2.08), p=0.153, respectively. 5 year overall and disease specific survival rates were 92.1% (89.1-95.1) vs. 86.8% (83.0-90.6), p=0.052 and 97.6% (95.9-99.4) vs. 96.4% (94.2-98.6), p=0.473 and 10 year overall and disease specific survival rates were 63.6% (55.7-71.5) vs. 63.2% (54.7-71.7), p=0.429 and 87.2% (81.0-93.3) vs. 87.2% (80.9-93.6), p=0.838 for arm 1 and arm 2, respectively. There were no significant differences in the rates of biochemical, regional or distant failure between arms. Conclusions: Our study shows that long term AB can be safely reduced from 36 to 18 months without compromising outcomes. Analysis of treatment impact on quality of life is now under review. Source of Funding: AstraZeneca Pharmaceuticals Grant. Clinical trial information: Clinical Trials.gov, #NCT00223171.

Treatment of metastatic spinal cord compression: cepo review and clinical recommendations

BACKGROUND

Metastatic spinal cord compression (mscc) is an oncologic emergency that, unless diagnosed early and treated appropriately, can lead to permanent neurologic impairment. After an analysis of relevant studies evaluating the effectiveness of various treatment modalities, the Comité de l'évolution des pratiques en oncologie (cepo) made recommendations on mscc management.

METHOD

A review of the scientific literature published up to February 2011 considered only phase ii and iii trials that included assessment of neurologic function. A total of 26 studies were identified.

RECOMMENDATIONS

Considering the evidence available to date, cepo recommends that cancer patients with mscc be treated by a specialized multidisciplinary team.dexamethasone 16 mg daily be administered to symptomatic patients as soon as mscc is diagnosed or suspected.high-loading-dose corticosteroids be avoided.histopathologic diagnosis and scores from scales evaluating prognosis and spinal instability be considered before treatment.corticosteroids and chemotherapy with radiotherapy be offered to patients with spinal cord compression caused by myeloma, lymphoma, or germ cell tumour without sign of spinal instability or compression by bone fragment.short-course radiotherapy be administered to patients with spinal cord compression and short life expectancy.long-course radiotherapy be administered to patients with inoperable spinal cord compression and good life expectancy.decompressive surgery followed by long-course radiotherapy be offered to appropriate symptomatic mscc patients (including spinal instability, displacement of vertebral fragment); andpatients considered for surgery have a life expectancy of at least 3-6 months.

Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure

Acute respiratory failure (ARF) is the leading reason for intensive care unit (ICU) admission in patients with cancer. The aim of this study was to identify early predictors of death in patients with cancer admitted to the ICU for ARF who were not intubated at admission. We conducted analysis of a prospective randomized controlled trial including 219 patients with cancer with ARF in which day-28 mortality was a secondary endpoint. Mortality at day 28 was 31.1%. By multivariate analysis, independent predictors of day-28 mortality were: age (odds ratio [OR] 1.30/10 years, 95% confidence interval [CI] [1.01-1.68], p = 0.04), more than one line of chemotherapy (OR 2.14, 95% CI [1.08-4.21], p = 0.03), time between respiratory symptoms onset and ICU admission > 2 days (OR 2.50, 95% CI [1.25-5.02], p = 0.01), oxygen flow at admission (OR 1.07/L, 95% CI [1.00-1.14], p = 0.04) and extra-respiratory symptoms (OR 2.84, 95%CI [1.30-6.21], p = 0.01). After adjustment for the logistic organ dysfunction (LOD) score at admission, only time between respiratory symptoms onset and ICU admission > 2 days and LOD score were independently associated with day-28 mortality. Determinants of death include both factors non-amenable to change, and delay in ARF management. These results suggest that early intensive care management of patients with cancer with ARF may translate to better survival.

Biomarkers for acute kidney injury in critically ill patients

Acute kidney injury (AKI) is a common and frequently fatal illness in critically ill patients, with a high associated-mortality. Early recognition of kidney injury and prompt corrective measures may improve outcome. Finding an early, accurate and reproducible biomarker for AKI is a research priority. In recent years, many urinary or plasma proteins have been investigated, some of them promising, but the ideal biomarker remains to be discovered. Cystatin C, neutrophil gelatinase-associated lipocalin, interleukin-18, fatty acid-binding proteins and kidney injury molecule 1 seem to be more accurate markers for AKI as compared with the traditional serum creatinine. However, their ability to predict worsening of AKI and need for renal replacement therapy (RRT) is not clear, and current available data are insufficient to recommend the use of these biomarkers routinely for clinical decision-making. Thus, using a combination of different urinary and plasma biomarkers and clinical observations, such as oliguria, may modify the clinical variability for therapeutic interventions, such as RRT initiation, and improve outcome. The purpose of this review was to summarize recent findings concerning biomarkers for AKI, especially in the intensive care unit setting, to highlight their strengths and weaknesses, and to determine their usefulness in clinical practice.

Severe post-renal acute kidney injury, post-obstructive diuresis and renal recovery

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The pathophysiology of post-renal acute kidney injury (PR-AKI), i.e. caused by urinary tract obstruction, has been extensively studied in animal models but clinical studies on this subject are outdated, and/or have focused on the mechanisms of 'post-obstructive diuresis' (POD), a potentially life-threatening polyuria that can develop after the release of obstruction. In severe PR-AKI, the risk of occurrence of POD is high. POD occurrence predicts renal recovery without the persistence of severe chronic kidney failure. In the present study, the occurrence of POD and the persistence of chronic renal sequelae could be predicted early from clinical variables at admission before the release of obstruction.

OBJECTIVE

• To identify predictors of post-obstructive diuresis (POD) occurrence or severe chronic renal failure (CRF) persistence after the release of urinary tract obstruction in the setting of post-renal acute kidney injury (PR-AKI).

PATIENTS AND METHODS

• Bi-centre retrospective observational study of all patients with PR-AKI treated in two intensive care units (ICUs) from 1998 to 2010. • Clinical, biological and imaging characteristics on admission and after the release of obstruction were analysed with univariate and, if possible, multivariate analysis to search for predictors of (i) occurrence of POD (diuresis >4 L/day) after the release of obstruction; (ii) persistence of severe CRF (estimated glomerular filtration rate <30 mL/min/1.73 m(2), including end-stage CRF) at 3 months.

RESULTS

• On admission, median (range) serum creatinine was 866 (247-3119) µmol/L. • POD occurred in 34 (63%) of the 54 analysable patients. On admission, higher serum creatinine (Odds ratio [OR] 1.002 per 1 µmol/L, 95% confidence interval [CI] 1.000-1.004, P = 0.004), higher serum bicarbonate (OR 1.36 per 1 mmol/L, 95% CI 1.13-1.65, P < 0.001), and urinary retention (OR 6.96, 95% CI 1.34-36.23, P = 0.01) independently predicted POD occurrence. • Severe CRF persisted in seven (21%) of the 34 analysable patients, including two (6%) cases of end-stage CRF. Predictors of severe CRF persistence after univariate analysis were: lower blood haemoglobin (P < 0.001) and lower serum bicarbonate (P = 0.03) on admission, longer time from admission to the release of obstruction (P = 0.01) and absence of POD (P = 0.04) after the release of obstruction.

CONCLUSIONS

• In severe PR-AKI treated in ICU, POD occurrence was a frequent event that predicted renal recovery without severe CRF. • POD occurrence or severe CRF persistence could be predicted early from clinical and biological variables at admission before the release of obstruction.

[Therapeutic of respiratory manifestations at the early phase of acute myeloid leukaemia]

The effective management of the respiratory manifestations at the early phase of acute myeloid hemopathies, especially acute myeloid leukaemia, frequently requires a close collaboration between hematologists, pulmonologists and intensivists. Dominated by infectious etiologies, there are however "specific" disease entities that should not be neglected in the diagnostic and therapeutic approach. These include lung leukostasis, leukemic lung infiltration, the cell lysis pneumopathy and the secondary alveolar proteinosis. These were the subject of a review in the Revue des Maladies Respiratoires published in 2010. We wished to review the management of these clinical situations, the severity of which mean patients frequently require intensive care unit admission. We are only able to make proposals for management here as there is little consensus, except in the metabolic care of tumour lysis syndrome. These data must therefore be reinterpreted regularly as new publications become available.

Acute exacerbation of idiopathic pulmonary fibrosis: outcome and prognostic factors

BACKGROUND

Acute exacerbation is a substantial cause of death in patients with idiopathic pulmonary fibrosis with poorly described prognostic factors.

OBJECTIVES

To review the features associated with acute exacerbation of idiopathic pulmonary fibrosis and assess its prognostic factors.

METHODS

Thirty-seven occurrences of acute exacerbation of idiopathic pulmonary fibrosis were retrospectively reviewed in the medical records of 27 patients. Clinical presentation, radiographic studies, pulmonary function tests, laboratory data, treatment, and outcome were analyzed.

RESULTS

Acute exacerbation of idiopathic pulmonary fibrosis occurred more frequently between December and May (75.7%) than between June and November (24.3%) (p = 0.01). In-hospital mortality was 27% and median survival was 4.2 months (range 0.2-36.6). Significant differences between nonsurvivors and survivors included the time elapsed between their admission and the initiation of treatment for acute exacerbation (6 vs. 3.1 days, p = 0.04), lactate dehydrogenase levels at admission (801 vs. 544.6 IU/l, p = 0.002), impairment of the prior forced vital capacity (51.2 vs. 65%, p = 0.01) and diffusing capacity for carbon monoxide (21.7 vs. 34%, p = 0.01). Furthermore, the evolution of gas exchange in the first 10 days after the initiation of treatment was associated with in-hospital and long-term mortality.

CONCLUSIONS

Acute exacerbations of idiopathic pulmonary fibrosis are more frequent during winter and spring. The time between admission and initiation of treatment is a new reported prognostic factor that should be investigated further. This finding highlights the need for a fast diagnostic approach that should probably be standardized. Early gas exchange modifications reflect the response to treatment and predict the prognosis.

Dexamethasone in patients with acute lung injury from acute monocytic leukaemia

The use of steroids is not required in myeloid malignancies and remains controversial in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). We sought to evaluate dexamethasone in patients with ALI/ARDS caused by acute monocytic leukaemia (AML FAB-M5) via either leukostasis or leukaemic infiltration. Dexamethasone (10 mg every 6 h until neutropenia) was added to chemotherapy and intensive care unit (ICU) management in 20 consecutive patients between 2005 and 2008, whose data were compared with those from 20 historical controls (1994-2002). ICU mortality was the primary criterion. We also compared respiratory deterioration rates, need for ventilation and nosocomial infections. 17 (85%) patients had hyperleukocytosis, 19 (95%) had leukaemic masses, and all 20 had severe pancytopenia. All patients presented with respiratory symptoms and pulmonary infiltrates prior to AML FAB-M5 diagnosis. Compared with historical controls, dexamethasone-treated patients had a significantly lower ICU mortality rate (20% versus 50%; p = 0.04) and a trend for less respiratory deterioration (50% versus 80%; p = 0.07). There were no significant increases in the rates of infections with dexamethasone. In conclusion, in patients with ALI/ARDS related to AML FAB-M5, adding dexamethasone to conventional chemotherapy seemed effective and safe. These results warrant a controlled trial of dexamethasone versus placebo in AML FAB-M5 patients with noninfectious pulmonary infiltrates.

Diagnostic strategy for hematology and oncology patients with acute respiratory failure: randomized controlled trial

RATIONALE

Respiratory events are common in hematology and oncology patients and manifest as hypoxemic acute respiratory failure (ARF) in up to half the cases. Identifying the cause of ARF is crucial. Fiberoptic bronchoscopy with bronchoalveolar lavage (FO-BAL) is an invasive test that may cause respiratory deterioration. Recent noninvasive diagnostic tests may have modified the risk/benefit ratio of FO-BAL.

OBJECTIVES

To determine whether FO-BAL in cancer patients with ARF increased the need for intubation and whether noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL.

METHODS

We performed a multicenter randomized controlled trial with sample size calculations for both end points. Patients with cancer and ARF of unknown cause who were not receiving ventilatory support at intensive care unit admission were randomized to early FO-BAL plus noninvasive tests (n = 113) or noninvasive tests only (n = 106). The primary end point was the number of patients needing intubation and mechanical ventilation. The major secondary end point was the number of patients with no identified cause of ARF.

MEASUREMENTS AND MAIN RESULTS

The need for mechanical ventilation was not significantly greater in the FO-BAL group than in the noninvasive group (35.4 vs. 38.7%; P = 0.62). The proportion of patients with no diagnosis was not smaller in the noninvasive group (21.7 vs. 20.4%; difference, -1.3% [-10.4 to 7.7]).

CONCLUSIONS

FO-BAL performed in the intensive care unit did not significantly increase intubation requirements in critically ill cancer patients with ARF. Noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL for identifying the cause of ARF. Clinical trial registered with www.clinicaltrials.gov (NCT00248443).

Spirometer‐dependence of vital capacity in ALS: Validation of a portable device in 52 patients

Since the evaluation of vital capacity (VC) needs to be carried out every three months in patients with amyotrophic lateral sclerosis (ALS), a portable spirometer would be of value in clinical practice. Over the follow-up of 52 ALS patients, we compared the values of slow vital capacity measured by two spirometers: a reference flow-metered spirometer based on a Hans-Rudolph pneumotachograph and a portable Venturi spirometer. The objectives were to analyse the overall concordance of the measurements from the two devices and determine a discordance cut-off. The correlation between measurements was high (r = 0.936) and significant (p<10(-20)). Bland and Altman analysis showed that the measurements were concordant at a statistical risk of 5%; nevertheless, on examination of the raw differences between the measurements, two sub-populations could be identified on either side of the 56% cut-off where the means of the differences were significantly different (p<0.0001). The 56% cut-off was also statistically significant in plotting differences against the coefficient of variations of the data pairs expressed as (100 x s/mean). The differences observed between the two spirometers could be explained by technical differences between the devices as well as by an increase in variability with progression of the disease. In conclusion, this study demonstrates that a portable spirometer can be used reliably at the bedside. For values of vital capacity below the discordance cut-off of 56%, vital capacity should be determined by operators trained in pulmonary function examinations.